Application for Employment

Thank you for considering Union County General Hospital in your job search. Union County General Hospital is an equal employment opportunity employer and does not discriminate on the basis of sex, age, race, color, religion, national origin, mental or physical disability, marital status, uniformed services status or (any state protected classifications). No application will be rejected as a result of a disability that, with reasonable accommodation, does not prevent performance of the essential job duties.

CONFIDENTIAL

Personal Information

Last Name *

First Name *

Middle Initial

Street Address *

City and State *

Zip Code *

Home Phone Number *

Work Phone Number

Date You Can Begin *

E-mail Address *

Position Applied For *

Salary Desired *

Name of High School

City and State of High School

Last Year Completed

Did You Graduate?

Name of College or University

City and State of College/University

How Many Years Completed?

Degree?

Name of Other Schools

City and State of Other Schools

How Many Years Completed?

Certificate or License

Software Applications

Other Skills

Employment Record

Please list your most recent jobs first. Include military service as part of your employment record. If you have a resume, please upload it as well.

(if hired, you will be required to provide identification to prove eligibility for employment)

Have you ever been employed or attended school using any other name? *

If yes, please indicate names previously used

Have you ever been convicted, pled guilty or no contest, or forfeited bond or bail for any crime other than traffic violations? *

If yes, please explain

Are you able to perform the primary duties of the job as outlined in the newspaper advertisement, announcement, posting, job line, job description, with or without reasonable accommodation? *

If no, please explain

Do you have any employment restrictions resulting from a non-compete or confidentiality agreement? *

If yes, please explain

Additional Information

Please use the space provided to list any additional employers, periods of time not worked, or any other information that you believe we should know in considering your application for employment.

Initial *

I certify that I have answered the above questions truthfully and have not withheld any information relative to my application. I understand that any falsification, misrepresentation, or omission, as well as any misleading statements or omissions of the application information, attachments, and supporting documents generally will result in denial of employment or immediate termination, if discovered after hire.

Initial *

I authorize Union County General Hospital to thoroughly investigate my references, work record, education and other matters related to my suitability for employment, and further authorize the references I have listed to disclose to the company any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I release Union County General Hospital, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

Initial *

I authorize Union County General Hospital to investigate whether I have a criminal record of convictions, and, if so, the nature of such convictions and all the surrounding circumstances of the conviction.

Initial *

If hired, I recognize the rules and policies of Union County General Hospital. I understand that my employment and compensation can be terminated at any time, with or without cause, and with or without notice, at the option of Union County General Hospital of myself. I understand that the Administrator of the company is the only person who will ever have the authority to create any other terms of employment and/or to enter into any employment contract and that all such contracts must be in writing and signed by both parties. However, I also understand that unless otherwise stated in an employment contract, the company may change, withdraw and interpret other policies (including wages, hours and working conditions) as it deems appropriate.

Initial *

I understand and acknowledge that I may be required to submit to a physical examination, including drug test. Additionally, I hereby authorize the release of the results of such an examination to Union County General Hospital for their use in evaluating my suitability for employment. Further, I release the examining facility and Union County General Hospital from any and all liability, and from any damage that may result from the release of such information.

Signature *

Important Information To Know Before Filling Out An Application for Employment With UNION COUNTY GENERAL HOSPITAL
1. All areas of the application must be filled out completely and accurately. Please fill in the required information directly on the application and do not indicate “see resume”.

2. If you are offered a position with Union County General Hospital be aware that we may verify all of the information that you have written on the application, as well as your resume. If there is a discrepancy in your information, the job offer may be withdrawn. It is important to be sure that what you have written is correct.

3. If you have any questions about completing the application, it is important to please ask the Union County General Hospital representative who has been assisting you.

My submission indicates that I have read and understand the importance of supplying accurate information on the application. I am also aware of the possibility of an offer of employment being withdrawn if any of the information is not correct.